1 Basics of Tobacco Cessation Intervening with tobacco users in a systematic way, consistently identifying tobacco users and delivering an appropriate intervention with every user will significantly increase the number of clients who quit using tobacco

2 Tobacco use is the chief preventable cause of illness and death in our society 14,000Drugs 17,000AIDS 19,000Homicide 30,000Suicide 41,000Motor Vehicles 81,000Alcohol 436,000$moking Smoking-Attributable Morbidity Mortality and Economic Costs, CDC, 2002

3 Smoking Related Diseases In addition to being a strong factor in the development of lung cancer, cigarette smoking also increases the risk of a number of other cancers, including mouth and throat cancers, bladder, pancreatic, cervical and kidney cancer. Cancer is not the only disease caused by smoking. It also causes most cases of COPD (chronic obstructive pulmonary disease), and some 90 percent of COPD- related deaths are caused by smoking. Heart disease and strokes are often linked to smoking, and a number of childhood diseases and conditions are linked to smoking during pregnancy and/or secondhand smoke.

4 Why don’t they just quit? Approximately 50% of current smokers reported making a serious attempt to quit during the last year Nearly 80% of all current smokers indicate that they want to quit smoking The causes of tobacco dependence are complex and vary somewhat from person to person Biological Cultural Psychological

5 Biological Factors True drug dependence on nicotine Nicotine affects essential brain structures associated with feelings of award and arousal These changes persist long after use stops Learned behaviors that form tobacco use patterns Withdrawal symptoms and cravings

6 Psychological Factors Reinforced, conditioned drug taking behavior Habit, automatic behavior A coping mechanism for stress, lonely, bored, happy, angry Self medicate for depression, anxiety

7 Cultural Factors Group identity Social activity Cultural Practice National marketing by the tobacco industry versus having a primary care giver ask and advise

8 Who Is Ready To Quit? Not everyone who uses tobacco is ready to quit Most have tried, some multiple times At any given time 20% are ready 40% are thinking about it 40% are not ready

9 The Readiness to Change Model

10 Readiness to Change Model Not Ready to Quit: Has no intention to quit within the next 6 months Thinking About Quitting: Intends to quit within the next 6 months Ready to Quit: Is willing to set a Quit Date within the next 30 days Quitting: Has remained tobacco free for less than 6 months Staying Quit: Has remained tobacco free for more than 6 months Relapse: Is using tobacco again after a period of being tobacco free Because tobacco dependence is a chronic condition, tobacco users typically cycle through multiple periods of relapse

11 The 5 A s Ask, Advise, Assess, Assist, Arrange A brief tobacco intervention Relevant to the person receiving it Should include both the risks of using tobacco and the rewards for quitting Should be repeated to encourage tobacco users to quit and allow for changes in their readiness to quit

12 Ask Ask about tobacco use at every encounter with every person Displaying visible messages makes asking about tobacco use a normal and expected part of each patient encounter Include tobacco use as a vital sign: Have you ever used tobacco? Do you use tobacco now? Does anybody else in your home use tobacco? I

13 Advise In a clear, strong, and personalized manner, advise every tobacco user to quit “One of the best things you can do to improve your health and the health of your family is to quit smoking. We can help.” Personalize the message by tying tobacco use to the person’s motivation Health Status Impact of their tobacco use on others Pregnancy Costs – social and economic

14 Assess Determine the tobacco user’s willingness to make a quit attempt at the present time Have you thought about quitting tobacco? When do you think you might be ready to quit? Are you willing to quit in the next 30 days? Provide information specific to that person

15 Assist Tobacco users who are willing to make a quit attempt need help in developing a Quit Plan Setting a Quit Date Identifying social support Providing specific problem – solving suggestions Giving information about medications Providing self-help materials Referring to intensive services if interested Assist the tobacco user who is not ready to quit

16 It is not necessary or helpful to try to talk someone into quitting People who are unwilling or unready to quit to make a quit attempt may be ready next time Avoid being judgmental or trying to pressure the tobacco user into quitting Offer written materials that emphasize the benefits of quitting Provide a brief motivational intervention using the 5 R s

17 5 R s Relevant information Risks Rewards Roadblocks Repetition promotes effective outcomes

18 Arrange Arrange for follow-up whenever possible Within a week for a tobacco user making a quit attempt Ask about tobacco status Congratulate people who are tobacco free and support them in staying Tabasco free Support people who have relapsed and assist them in making a new quit attempt

19 2 A s and R Ask Advise Refer

20 Motivational Interviewing A directive client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence Motivation to change is elicited from the client It is the client’s task to articulate and resolve their ambivalence Stages of Change Model: Precomtemplation Contemplation Preparation Action Maintenance Relapse Eliciting change talk results in the client hearing themselves advocate for their own change

21 Our job is to help facilitate clients moving to the next stage Open-ended questions Affirm Reflect what has been said Summarize Desire Ability Reasons Need Steps taken Commitment Developing discrepancy and increase motivation for change This really works

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23 Psychiatric Nurse Counseling Points Breaking Barriers and Implementing Changes “The Significance of Tobacco Dependence in Persons with Mental Illness” July 2010, Vol 1, No 1 “Delivering Effective Pharmacologic and Nonpharmacologic Interventions for Tobacco Dependence in Persons with Mental Illness” September 2010, Vol 1, No 2 “Treating Tobacco Dependence in Persons with Mental Illness: Identifying Challenges and Opportunities” December 2010, Vol 1, No 3

24 Resources Ohio Quit Line QUIT-NOW The Breathing Association Laura Atkinson, Tom Houston, Gretchen Clark Hammond Association for the Treatment of Tobacco Use & Dependence Center for Evidence Based Practices Tobacco: Recovery Across the Continuum And the usual suspects...